Homebound Instruction Medical Certification Of Need (Page 2 of 2) in pdf

Students may receive instruction in the home, a health care facility, or any other approved facility as agreed

upon by the school division and parent or student who has reached the age of majority (eligible student).

If it is necessary for homebound instruction to continue beyond nine weeks, an extension or reauthorization

form, including treatment plan, progress towards treatment goals, and specific plans to transition the student

back to the school setting, will be required.

To be completed by the parent/guardian or eligible student.

Name of Parent/Guardian or Eligible Student: _______________________________________

Home Phone: __________________________

Work phone: _______________________

Cell Phone: ___________________________

Street Address: ________________________________________________________________

City:___________________________________ State:_________ Zip Code:_______________

Acknowledgement/Release: I acknowledge this request and agree with the need for homebound services. I

further acknowledge that the requested homebound services for students receiving special education services

shall be subject to review by the student’s IEP team pursuant to the Individuals with Disabilities Education

Act. I will provide an environment conducive to learning, ensure that a responsible adult is in the home for

the duration of instruction, or provide transportation to another agreed upon facility. I will keep appointments

with the homebound teacher or contact the teacher or homebound coordinator if an appointment must be

missed.

I understand that the local school division has established policies and procedures for homebound instruction

that provide more detail than this certificate of need.

By my signature, I authorize the release and exchange of medical information between the health care

provider, listed on the reverse side, or his/her designee, and school division personnel. My signature provides

the heath care provider(s) with the authorization necessary to disclose protected health information and

records regarding said student as it pertains to the condition for which homebound instructional services are

being requested. This authorization may be withdrawn at anytime in writing.

Please note: This form, including parental permission to contact the treating physician or psychologist,

must be fully completed in order for the student to be considered for homebound services. If you have

questions about completing this form, please contact:

___________________________________________________________________________.

_______________________________________________

___________________

Signature of Parent/Guardian or Eligible Student

Date

* The Code of Virginia § 54.1-2957.02 states “whenever any law or regulation requires a signature, certification, stamp, verification,

affidavit or endorsement by a physician, it shall be deemed to include a signature, certification, stamp, verification, affidavit or

endorsement by a nurse practitioner.”

Homebound Instruction Medical Certification Of Need Page 2